dietary factors, obesity and pediatric asthma … factors, obesity and... · increase in...

Dietary Factors, Obesity Dietary Factors, Obesity

and Pediatric Asthmaand Pediatric AsthmaPaul A. Greenberger, M.D., Paul A. Greenberger, M.D.,

FAAAAI, FACAAIFAAAAI, FACAAI

08000800--08250825

PGPG--1010

Dietary Factors and Weight ManagementDietary Factors and Weight Management

�� Paul A. Greenberger, M.D., FAAAAI, Paul A. Greenberger, M.D., FAAAAI,

FACAAIFACAAI

–– DisclosuresDisclosures

�� Mylan (Dey) advisory committeeMylan (Dey) advisory committee

�� AAAAI past presidentAAAAI past president

�� Misc Legal (APBA, immunology, drug allergy)Misc Legal (APBA, immunology, drug allergy)

ObjectivesObjectives

�� To review how to differentiate between To review how to differentiate between lack of conditioning in obese children from lack of conditioning in obese children from loss of asthma controlloss of asthma control

�� To consider when weight gain in childhood To consider when weight gain in childhood is most likely to contribute to asthma is most likely to contribute to asthma expressionexpression

�� To present information regarding what To present information regarding what dietary factors may be productive in dietary factors may be productive in reducing asthma induction and severityreducing asthma induction and severity

ObjectivesObjectives

�� To review how to differentiate between To review how to differentiate between lack of conditioning in obese children from lack of conditioning in obese children from loss of asthma controlloss of asthma control

�� To consider when weight gain in childhood To consider when weight gain in childhood is most likely to contribute to asthma is most likely to contribute to asthma expressionexpression

�� To present information regarding what To present information regarding what dietary factors may be productive in dietary factors may be productive in reducing asthma induction and severityreducing asthma induction and severity

To review how to differentiate between lack of To review how to differentiate between lack of

conditioning in obese children from loss of asthma conditioning in obese children from loss of asthma

controlcontrol

�� Control consists of 2 Control consists of 2

domainsdomains………….._______________ and.._______________ and

______________________________

NAEPP, NHLBI 2007NAEPP, NHLBI 2007

To review how to differentiate between lack of To review how to differentiate between lack of

conditioning in obese children from loss of asthma conditioning in obese children from loss of asthma

controlcontrol

�� Control consists of 2 Control consists of 2

domainsdomains……ImpairmentImpairment andand RiskRisk

Asthma Severity/Control

Asthma Severity/Control

Despite RecommendationsDespite Recommendations……..

•• More than 10% of children and More than 10% of children and

adolescents are over their recommended adolescents are over their recommended

weight weight …………

•• Cough, Breathlessness with Exercise, and Cough, Breathlessness with Exercise, and

WheezingWheezing in obese children and in obese children and

adolescents may lead to adolescents may lead to OVERDIAGNOSISOVERDIAGNOSIS

of asthma by physiciansof asthma by physicians

ObjectivesObjectives

�� To review how to differentiate between To review how to differentiate between lack of conditioning in obese children from lack of conditioning in obese children from loss of asthma controlloss of asthma control

�� To consider when weight gain in childhood To consider when weight gain in childhood is most likely to contribute to asthma is most likely to contribute to asthma expressionexpression

�� To present information regarding what To present information regarding what dietary factors may be productive in dietary factors may be productive in reducing asthma induction and severityreducing asthma induction and severity

Conditioning is a Function of Conditioning is a Function of

�� Increase in ventilationIncrease in ventilation during exercise during exercise (respiratory rate and flow rate)(respiratory rate and flow rate)

�� Increase in cardiac outputIncrease in cardiac output (V/Q homogeneous or (V/Q homogeneous or low and high areas of V/Q from acute asthma)low and high areas of V/Q from acute asthma)

�� Neuroendocrine adaptationNeuroendocrine adaptation (peak plasma (peak plasma concentration of epinephrine)concentration of epinephrine)

�� Metabolic adaptationMetabolic adaptation (aerobic and anaerobic (aerobic and anaerobic capacity) (both can be decreased in asthma if capacity) (both can be decreased in asthma if FEVFEV1 1 is reduced)is reduced)

�� Respiratory functionRespiratory function (airways obstruction)(airways obstruction)

Regarding Asthma, does the child Regarding Asthma, does the child

havehave

�� Lack of ventilatory reserve (bronchoconstriction, Lack of ventilatory reserve (bronchoconstriction, chest wall deformity)chest wall deformity)

�� Muscle deconditioningMuscle deconditioning

�� Cardiac limitationCardiac limitation

�� Uncontrolled Allergic Rhinitis or Rhinosinusitis?Uncontrolled Allergic Rhinitis or Rhinosinusitis?

�� Concomitant chronic disease (CF?)Concomitant chronic disease (CF?)

�� Poor self esteemPoor self esteem

�� Lack of confidence in asthma therapyLack of confidence in asthma therapy

�� AsthmaAsthma

12 year old with persistent mild12 year old with persistent mild--

moderate asthma since age 2 years; moderate asthma since age 2 years;

Allergic Rhinitis; OverweightAllergic Rhinitis; Overweight

Response to Therapyfor Exacerbations

Responds quickly

Responds to combination

ICS/LABA; occasionalprednisone

Slow to respond

12 year old with persistent mild12 year old with persistent mild--

moderate asthma since age 2 years; moderate asthma since age 2 years;

overweightoverweight

Response to Therapyfor Exacerbations

Responds quickly

Responds to combination

ICS/LABA; occasionalprednisone

Slow to respond

Slow or SubSlow or Sub--Optimal ResponsesOptimal Responses

�� NonNon--adherenceadherence

�� Overweight reduces responses to medications Overweight reduces responses to medications

(doubtful impairment in persistent mild, (doubtful impairment in persistent mild,

moderate asthma (JACI 2009;123:1328moderate asthma (JACI 2009;123:1328--34)34)

�� UnUn--recognized concurrent VCDrecognized concurrent VCD

�� HyperHyper--vigilant re symptom recognitionvigilant re symptom recognition

�� CoCo--morbidities relevantmorbidities relevant

�� DeDe--conditionedconditioned

�� Exercise induced hypocarbiaExercise induced hypocarbia

CoCo--Morbidities/IssuesMorbidities/Issues

�� GERD, NERD, LPR (atypical reflux)GERD, NERD, LPR (atypical reflux)

�� Sleep ApneaSleep Apnea

�� Allergens at home (pets, dust mites, fungi, Allergens at home (pets, dust mites, fungi, pests)pests)

�� Allergic rhinitis and/or CRSAllergic rhinitis and/or CRS

�� Adherence, selfAdherence, self--efficacy (recognition of efficacy (recognition of symptoms or change in PEF early)symptoms or change in PEF early)

�� Expectations (patient and/or family)Expectations (patient and/or family)

�� Social (overweight friends, family)Social (overweight friends, family)

�� SmokingSmoking

�� Low/insufficient Vitamin D Low/insufficient Vitamin D ≤≤ 30 ng/mL30 ng/mL

Exercise Induced Syndromes..Exercise Induced Syndromes..

�� AsthmaAsthma

�� Bronchoconstriction (no underlying Bronchoconstriction (no underlying

persistent asthma)persistent asthma)

�� RhinitisRhinitis

Exercise Induced BronchospasmExercise Induced Bronchospasm

Which Therapies Modify (reduce) Which Therapies Modify (reduce)

the Extent of EIB/EIAthe Extent of EIB/EIA

�� Albuterol, terbutalineAlbuterol, terbutaline

�� __________________________

�� __________________________

�� __________________________

�� __________________________

�� ________________________

�� ________________________

�� ________________________

�� ________________________

�� ________________________

Which Therapies Modify (reduce) Which Therapies Modify (reduce)

the Extent of EIB/EIAthe Extent of EIB/EIA

�� Albuterol, terbutalineAlbuterol, terbutaline

�� LABA (rapid onset)LABA (rapid onset)

�� CromolynCromolyn

�� NedocromilNedocromil

�� Leukotriene Receptor Leukotriene Receptor

AntagonistAntagonist

�� Leukotriene Synthesis Leukotriene Synthesis

ModifierModifier

�� Inhaled Inhaled

corticosteroids (not corticosteroids (not

immediately effective)immediately effective)

�� TheophyllineTheophylline

�� Ca Channel BlockersCa Channel Blockers

�� Nasal breathingNasal breathing

�� Warm, moist airWarm, moist air

Is There Real Disease Here in an Obese Is There Real Disease Here in an Obese

Child/Adolescent with Shortness of Breath Child/Adolescent with Shortness of Breath

and Wheezing ?and Wheezing ?

�� Coughing with deep inspiration Coughing with deep inspiration (in non(in non--asthma patients, at total lung capacity, asthma patients, at total lung capacity, resistance decreases; in asthma, it can go resistance decreases; in asthma, it can go up and cause coughing)up and cause coughing)

�� Abnormal expiratory flow rates Abnormal expiratory flow rates and and reversibilityreversibility or truncated inspiratory loop or truncated inspiratory loop on a flowon a flow--volume loopvolume loop

�� What has been the response to What has been the response to medications?...medications?...worsening if taken offworsening if taken off of or of or undertreated with medications?undertreated with medications?

�� Poor effort on spirometry?Poor effort on spirometry?

L/S

Exercise Induced Hyperventilation (Ann Allergy Asthma Exercise Induced Hyperventilation (Ann Allergy Asthma

Immunol 1999;82:574Immunol 1999;82:574--78)78)

Exercise Induced Hyperventilation (Hypocapnia)Exercise Induced Hyperventilation (Hypocapnia)

�� Reassurance of child or adolescent Reassurance of child or adolescent

�� Try to suppress hyperventilationTry to suppress hyperventilation

�� Avoid excessive pharmacotherapyAvoid excessive pharmacotherapy

What About Excluding Asthma?

� Demonstrate overdiagnosis or remission

� Negative bronchial provocation challenge with mannitol.. (recently available with high specificity--if no disease, test is negative)

� Examine if symptomatic

� Identify other explanations

� Keep an open mind

ObjectivesObjectives

�� To review how to differentiate between To review how to differentiate between lack of conditioning in obese children from lack of conditioning in obese children from loss of asthma controlloss of asthma control

�� To consider when weight gain in childhood To consider when weight gain in childhood is most likely to contribute to asthma is most likely to contribute to asthma expressionexpression

�� To present information regarding what To present information regarding what dietary factors may be productive in dietary factors may be productive in reducing asthma induction and severityreducing asthma induction and severity

Obesity as a Socially Infectious Obesity as a Socially Infectious

Disease?Disease?

�� 17% of children, adolescents ages 217% of children, adolescents ages 2--19 19

years are obese in the U.S.years are obese in the U.S.

Waist/heightWaist

BMI > 30 kg/m2

Which Children?Which Children?

�� BMI BMI ≥≥ 40 kg/m40 kg/m22

�� OverweightOverweight if there is inadequate control if there is inadequate control

of asthma or prevention of EIBof asthma or prevention of EIB

�� At riskAt risk infants, toddlers, children, infants, toddlers, children,

adolescentsadolescents

To present information regarding what dietary To present information regarding what dietary

factors may be productive in reducing asthma factors may be productive in reducing asthma

induction and severityinduction and severity

�� PrePre--NatalNatal……..avoid excessive weight gain..avoid excessive weight gain

�� PrePre--NatalNatal……..pro and pre..pro and pre--biotics (modestbiotics (modest--

to keep weight down)to keep weight down)

�� Age up to 2 yrsAge up to 2 yrs…….avoid overfeeding and .avoid overfeeding and

rapid growth (top 20rapid growth (top 20thth percentile)percentile)

�� Mediterrannean dietMediterrannean diet

�� Sufficient sleep (when using diet)Sufficient sleep (when using diet)

�� Vitamin C, apples, pears?Vitamin C, apples, pears?

Associations of maternal and children adherence to a Mediterranean diet with wheeze and atopy in Menorcan children at age 6.5 years.

Chatzi L et al. Thorax 2008;63:507-513

©2008 by BMJ Publishing Group Ltd and British Thoracic Society

Is Having Asthma A Risk Factor for Is Having Asthma A Risk Factor for

Obesity?Obesity?

�� YesYes

�� NoNo

Arch Pediatr Adolesc Med 1998;152:1197Arch Pediatr Adolesc Med 1998;152:1197--12001200 The The

Relationship Between Asthma and Obesity in Urban Relationship Between Asthma and Obesity in Urban

Minority Children and AdolescentsMinority Children and Adolescents

�� Asthma is a risk factor for obesity in Asthma is a risk factor for obesity in children ages 4children ages 4--10.5 yrs and 1110.5 yrs and 11--16 yrs16 yrs

�� The The severityseverity of asthma was not associated of asthma was not associated with obesitywith obesity

�� Asthma (Symptoms and MD confirmed Asthma (Symptoms and MD confirmed wheezing)wheezing)

�� Percent overweight was reported as a Percent overweight was reported as a continuous variable so that overweight continuous variable so that overweight was >50was >50thth percentile for BMIpercentile for BMI

Weight Matters...Arch Pediatr Adolesc Med 1998;152:1197Weight Matters...Arch Pediatr Adolesc Med 1998;152:1197--1200 1200

The Relationship Between Asthma and Obesity in Urban The Relationship Between Asthma and Obesity in Urban

Minority Children and AdolescentsMinority Children and Adolescents

Can A Child or Adolescent with Asthma Be Can A Child or Adolescent with Asthma Be

Fit (Conditioned) and Overweight?Fit (Conditioned) and Overweight?

�� YesYes

�� NoNo

Observations re Obesity Observations re Obesity

�� With increasing bronchoconstriction, there With increasing bronchoconstriction, there

is greater mechanical disadvantage eg is greater mechanical disadvantage eg

higher FRC and lower Inspiratory Capacity higher FRC and lower Inspiratory Capacity

which causes GREATER DYSPNEAwhich causes GREATER DYSPNEA

�� During bronchoconstriction, inspiratory During bronchoconstriction, inspiratory

muscles apply radial traction on the muscles apply radial traction on the

airways to support caliber (tidal volume airways to support caliber (tidal volume

and ventilation)and ventilation)

Observations re ObesityObservations re Obesity

�� Severity of dyspnea is perceived to be Severity of dyspnea is perceived to be

greater in obese patients with asthma for greater in obese patients with asthma for

the same level of bronchoconstrictionthe same level of bronchoconstriction

Advice/ConclusionsAdvice/Conclusions

�� Overweight status is an Overweight status is an immediate alertimmediate alert for for

attention to weight control or weight attention to weight control or weight

loss/physical conditioning and asthma controlloss/physical conditioning and asthma control

�� Overweight status has modest negative effects Overweight status has modest negative effects

on responses to monotherapy with ICS, not to on responses to monotherapy with ICS, not to

montelukast or ICS/LABA but in studies is not a montelukast or ICS/LABA but in studies is not a

major contributor to lack of asthma controlmajor contributor to lack of asthma control

�� Verify improvement with interventionsVerify improvement with interventions

SummarySummary

�� ““The mind can absorb only what the seat The mind can absorb only what the seat

can endurecan endure””

J Appl Physiol 2010;108:206J Appl Physiol 2010;108:206--11 11

35 y/o (BMI 42)35 y/o (BMI 42)--nonnon--asthmaasthma

Preserved Flow Rates but Reduced TLC, FRC and Preserved Flow Rates but Reduced TLC, FRC and

VCVC

Loss of Protective Effect of Deep (Bronchodilating) Loss of Protective Effect of Deep (Bronchodilating)

Inspiration with Obesity during Methacholine Inspiration with Obesity during Methacholine

Challenge (JACI 2005;115:1100Challenge (JACI 2005;115:1100--5)5)

Response to BronchoprovocationResponse to Bronchoprovocation

AJRCCM 2008;177:970AJRCCM 2008;177:970--55

�� Perception of dyspnea and influence of obesityPerception of dyspnea and influence of obesity

�� 30 Female Adults with asthma30 Female Adults with asthma

�� Methacholine challengeMethacholine challenge

�� Little change in TLC; increases in Residual Little change in TLC; increases in Residual

Volume similar despite differences in BMIVolume similar despite differences in BMI

�� FEVFEV11 decreased 28% as expecteddecreased 28% as expected

�� Numerical but no significant differences in VAS Numerical but no significant differences in VAS

for dyspnea; no relationship with BORG for dyspnea; no relationship with BORG

scorescore…………butbut………………..

Do Obese Patients with Asthma Sense Airway Do Obese Patients with Asthma Sense Airway

Closure Differently Pre and Post Methacholine?Closure Differently Pre and Post Methacholine?

BMI 20-24.9BMI 25-30.9 BMI 31-45